Facebook
Twitter
LinkedIn
Email
 |
Checking for direct PDF access through Ovid | |
Excerpt
Left unsaid is the meaning of “NECESSARY.”
Does this imply a comment from the surgeon or the conclusion of a patient when the decision is based on an ill-considered reaction to an “intolerable” pain and a perhaps misapprehension of what is really wrong?
My theory, carefully constructed, is that the patient more often sees a rapid and relatively painless solution with the knife. Unfortunately, a final outcome could be a discectomy followed by a fusion (?instrumentation) and more discomfort, resulting in removal of the metal, continued “intolerable pain,” and, finally, referral to a pain center, which then recommends a morphine pump or a spinal cord stimulator.
This sequence of events is so often the ultimate outcome when the first touch is a scalpel that my conditioned response to that question, “What is the indication for surgery in acute radiculopathy?” is, “Only when the disk is protruding through the skin.”
This, of course, is hyperbole.
But it makes a point!
Do not undertake the invasive approach lightly. We physiatrists see these patients after all the surgical trauma but the patient is still disabled by severe pain.
Let us intercept these vulnerable people early in their course of treatment and improve the final result.
We can, of course, with the help of Mother Nature, exercises, and reassurance (heavy doses of the latter). In other venues, this is called counseling or, even more appropriately, education.
Some years ago, I was advised by an expert surgeon that he ascribed his best results in disk surgery to the almost immediate discectomy before Mother Nature's usual cure.
Would not this information make you uneasy when considering the disk operation?
The Agency for Health Policy and Research (Dept. HHS) recently released acute low back pain guidelines, and, unfortunately, they were too liberal in the surgical indications. They also mentioned “Neurologic Deficit” without specifying the need to use EDX to identify the degree and permanence of the weakness.
This is easily and accurately done with our high-technology electromyographic instruments. After five days, the clinical weakness can be separated into either the temporary or permanent category by stimulating the nerve to the weak muscle, measuring the compound muscle action potential (CMAP), and comparing the CMAP amplitude with the contralateral side.
The dying axons, of course, will not contribute to the CMAP.
Left unsaid is the conclusion that, if the clinical weakness is mostly NEURAPRAXIC (temporary), there is NO need for an operation, and, obviously, if there is permanent weakness, NO benefit will accrue from surgery.
Pain must not be an indication for surgery, even though it is of primacy to the patient.
PAIN is best handled CONSERVATIVELY!
In a recent issue of another PM&R journal, there was a flurry of letters questioning the need for EDX in radiculopathy. The authors apparently only considered the use of EMG an aid to diagnosis but omitted EMG's essential role in prognosis and management, which opened the question of the “EDXIQ” of the authors.
